II. Physiology

  1. Images
    1. ankleMedialAndLateral.jpg
  2. Anterior tibial tendon contracts during heel strike while walking, controlling the how the forefoot contacts the ground
  3. Anterior tibial tendon specific functions
    1. Foot dorsiflexion (major function)
    2. Foot adduction
    3. Foot inversion

III. Causes

  1. Chronic overuse in age over 45 years
  2. Forced dorsflexion against resistance of a plantar flexed foot (eccentric stress on tibialis anterior tendon)
    1. Distance Running
    2. Soccer or football

IV. Risk Factors

  1. Women
  2. Overweight
  3. Runners (overuse injury, esp. with hills and increased mileage)

V. Symptoms

  1. Anterior ankle pain and medial midfoot pain
  2. Pain worse at night and also with activity

VI. Signs

  1. Pain (and possibly swelling) localized to the anteromedial ankle and foot overlying the anterior tibial tendon
    1. Palpable mass in low anterior leg if anterior tibial tendon rupture
  2. Weak and painful foot dorsiflexion on resistance
  3. Gait may demonstrate a Foot Drop or Slapping gait
  4. Passive Stretching of anterior tibial tendon may result in pain
    1. Plantar flexion
    2. Hindfoot eversion
    3. Midfoot abduction
    4. Ankle pronation

VII. Differential Diagnosis

  1. Anterior Tibial Tendon Rupture
  2. Lumbar Radiculopathy
  3. Peroneal nerve palsy

VIII. Complications

  1. Complete peroneal tendon rupture (more common in age >50-60 years)

IX. Management

  1. Ankle Foot Orthotic (for dorsiflexion assistance) OR
  2. Immobilization (e.g. CAM walker boot)
    1. Start with 3 weeks of immobilization
    2. Next 3 weeks
      1. Range of motion Exercises AND
      2. Immobilization (e.g. CAM Walker boot) with ambulation only
  3. Foot dorsiflexion strengthening
  4. Orthopedic referral indications
    1. Complete peroneal tendon rupture
    2. Refractory Anterior Tibial Tendinopathy
      1. Consider surgical Debridement for refractory symptoms >5 months
      2. Grundy (2010) Foot Ankle Int 31(3): 212-9 [PubMed]

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